Citation Nr: 21075871 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 16-05 336 DATE: December 21, 2021 REMANDED Entitlement to service connection for hypertension is remanded. REASONS FOR REMAND The Veteran had active service from March 1976 to March 1979. This matter comes before the Board of Veterans' Appeals (Board) from an April 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. This matter has been before the Board in September 2018 and October 2021 for adequate medical opinions. 1. Entitlement to service connection for hypertension is remanded. In October 2021, the Board remanded this issue in order to obtain a VA examination and opinion to address whether the Veteran's hypertension was due to military service or to his service-connected knee disability. The examiner was asked to determine whether the Veteran's hypertension was at least as likely as not due to service or as least as likely as not caused or aggravated by the Veteran' bilateral knee disability. The Veteran was afforded a VA examination in November 2021. The examiner found that the Veteran's hypertension was less likely than not as due to service. The examiner noted that the Veteran had several blood pressure (BP) readings in service and was not diagnosed with hypertension in service or within a year of separation from service; he was first diagnosed with hypertension in 2009, 30 years after separation from service. The examiner also concluded that hypertension was less likely than not caused or aggravated by the Veteran's bilateral knee disability. By way of rationale, the examiner stated that the "Veteran was diagnosed with primary hypertension prior to SC left knee replacement therefore aggravation is not plausible." The Board finds this to be an illogical rationale, as the presence of a preexisting disorder that is subsequently made worse by a separate condition is the very nature of a disease that is subsequently aggravated by a service-connected disability. Aggravation is defined as the worsening beyond the natural progression of the disease, and even when the service-connected disability is not the cause of the claimed disorder, compensation can be paid for the degree of disability resulting from aggravation of the disability above its previous baseline. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310 (b). Moreover, and relatedly, the examiner failed to specifically address Board instructions to detail whether the Veteran's hypertension was caused or aggravated by his service-connected disability. The examiner failed to provide an opinion for both causation and aggravation. The Board notes that causation and aggravation are independent concepts and should have separate findings and rationales. See Atencio v. O'Rourke, 30 Vet. App. 74 (2018). As such, the examiner must provide separate findings and rationales relating to causation and aggravation. The Board therefore remands this issue in order to obtain an addendum medical opinion which adequately addresses whether the Veteran's hypertension has been caused or aggravated by his service-connected knee disability. Additionally, obesity can be an "intermediate step" between a service-connected disability and a current disability for secondary service connection purposes. See 38 C.F.R. § 3.310. To succeed on this claim, it must be shown that: (i) a service-connected disability caused him to become obese; (ii) obesity was a substantial factor in causing the secondary disability; and, (iii) the secondary disability would not have occurred but for the obesity. VAOPGCPREC 1-2017 (January 6, 2017). In this case, the medical evidence of record notes a lengthy history of morbid obesity. Additionally, the Veteran's obesity has been noted in relation to his service-connected bilateral knee condition, depressive disorder, and lumbar spine disability. Notably, the Veteran was shown to have gained significant weight following his total left knee replacement in 2015. See CAPRI record, dated November 28, 2018. Likewise, the Veteran's obesity has been noted to be a risk factor for hypertension. See CAPRI record, dated January 19, 2012. The Board cannot make a fully informed decision as to the issue on appeal because no VA examination has opined whether the Veteran's obesity/being overweight is an "intermediate step" between any or all of the Veteran's service-connected disabilities and his claimed hypertension. Accordingly, the examiner is also requested to render an opinion that addresses obesity as an intermediate step for secondary service connection. The matter is REMANDED for the following actions: 1. Obtain an opinion from an appropriate examiner regarding the Veteran's hypertension claim. The examiner is asked to answer the following: a. Is it at least as likely as not the Veteran's hypertension is (1) caused or (2) aggravated (beyond natural progression) by the Veteran's service-connected disabilities, to specifically include bilateral knee disabilities, and medications taken for those disorders. b. Is it at least as likely as not (a 50 percent or greater probability) that any or all of the Veteran's service-connected disabilities (including any medications taken for the service-connected disabilities) caused or aggravated the Veteran's obesity/being overweight including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. c.) If yes, is it at least as likely as not (a 50 percent or greater probability) that the obesity/being overweight caused or aggravated the Veteran's hypertension, including whether there is/was any incremental increase in disability or aggravation as a result of service? State whether there is/was a medically ascertainable increase in disability regardless of permanence. Any increase in disability should be described in terms of diagnosis, severity, and duration. The permanence of the aggravation is not at issue. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation (specifying the baseline level of disability and current level of severity, based on consideration of VA's rating schedule). (Continued on the next page) The examiner is reminded that causation and aggravation are separate inquiries, and therefore, separate findings and rationales should be provided for each one. A complete rationale for all opinions offered should be provided. A. MARSH II Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Kelsey Love, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.